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Nursing Diagnosis - Hypothermia : Definition, Related Factors, Outcomes and Interventions

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Hypothermia: Definition : Body temperature below the normal range Defining Characteristics : body temperature below normal range, cool, pale skin, dizziness, hypertension, increased heart rate, lack of coordination, piloerection, shivering, slow capillary refill Related Factors : alcohol and drug use, decreased metabolic rate, exposure to cold environment, extreme evaporative heat loss from skin, illness, inability to shiver, inadequate nutrition, poor clothing, medications, trauma NOC: Thermoregulation Thermoregulation: neonate Expected Outcomes: Body temperature in the normal range Pulse and respiratory rate are in the normal range NIC: Temperature Regulation Monitor temperature at least every 2 hours. Plan temperature monitoring continuously. Blood pressure monitor, pulse, and respiratory rate. Monitor skin color and temperature. Monitor signs of hyperthermia and hypothermia. Increase intake of fluids and nutrients. Cover the patient to prevent loss of body warmth. Teach patients ho
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Nursing Diagnosis Knowledge Deficit : Definition, Outcomes and Interventions

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Knowledge Deficit    Definition: Absence or deficiency of cognitive information related to a specific topic. Defining Characteristics: verbalization of the problem, inaccurate follow-through instructions, inaccurate performance of tests, inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic) Related Factors: lack of exposure, lack of recall, information misinterpretation, cognitive limitation, lack of interest in learning, unfamiliarity with information resources NOC: Kowlwdge: disease process Kowledge: Health behavior Expected Outcomes: Patients and families agree on diseases, conditions, prognosis and treatment programs Patients and families are able to perform the correct procedure Patients and families are able to explain what the nurse or other health team explains NIC: Teaching: Disease Process Give about the level of patient knowledge about the specific disease process. Explain the pathophysiology of the disease and how it relates to anatomy and
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Nursing Diagnosis and Interventions for Fear

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Nursing Diagnosis : Fear r/t invasive procedure, hospitalization, unfriendly experience. Fear Definition Response to perceived threat that is consciously recognized as a danger Defining characteristics: Panic Terror Avoidance or attack behavior Impulsive Pulse, respiration, systolic BP increases Anorexia Nauseous vomit Pale Stimulus as a threat Tired Tense muscles Sweat increases Uproar Tension increases Express fear Cry Protest Escape Outcomes : Fear Control The client : Don't attack or avoid scary sources. Use relaxation techniques to reduce fear. Able to control the response. Does not run away. Duration of fear decreases. Cooperative when done care and treatment. Anxiety Control The client : Adequate sleep. There is no physical manifestations. There is no behavioral manifestations. Want to interact socially. Interventions : Coping Enhancement Assess the patient's fearful response: objective and subjective data. Explain to the client / family about the disease process. Expla
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Deficient Fluid Volume related to Diarrhea

Nursing Care Plan for Diarrhea Nursing Diagnosis : Deficient Fluid Volume related to input decreases, loss of active fluid volume, failure in the regulatory mechanism Defining Characteristics: Weakness Thirsty Decreased skin turgor Mucous membrane / dry skin Pulse increases, blood pressure decreases, pulse pressure decreases Decreased capillary filling Change in mental status Decreased urine output Increased urine concentration Increased body temperature Hematocrit increases Sudden weight loss. Goal After implementation, fluid and electrolyte requirements are adequate, with the following criteria: Hydration Adequate skin hydration Blood pressure is within normal limits The pulse is palpable Moist mucous membrane Normal skin turgor Stable weight and within normal limits Eyelid - not concave Fontanela - not concave Normal urine output No fever There is no very thirst There is no short breaths Fluid Balance Normal blood pressure Palpable peripheral pulse There is no orthostatic hypotensi
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Appendicitis - Assessment, Nursing Diagnosis and Interventions

Assessment History: Data collected by nurses from clients with possible appendicitis include: age, sey, surgical history, and other medical history, oral / rectal barium administration, history of diit especially fibrous foods. a. Subjective Data Before surgery • Navel area pain radiates to the lower right abdomen • Nausea, vomiting, bloating • No appetite, fever • The right leg cannot be straightened • Diarrhea or constipation After surgery • Pain in the surgery area • Weak • Thirst • Nausea, bloating • Dizzy b. Objective data Before surgery • Tenderness at McBurney point • Muscle spasm • Tachycardia, tachypnea • Pale, nervous • Bowel noise is reduced or absent • Fever 38 - 38.5 degrees C After surgery • There are surgical wounds in the right lower quadrant of the abdomen • Attached infusion • There is a drain / gastric pipe • Reduced bowel sounds • Dry oral mucous membranes Laboratory examination • Leukocytes: 10,000 - 18,000 / mm3 • Netrophils increase by 75% • Increased WBC up to 2
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Nursing Care Plan for Hepatic Cirrhosis / Liver Cirrhosis

Hepatic cirrhosis is a chronic disease of the liver with inflammation and liver fibrosis which results in the distribution of hepatic structures and loss of most liver function. Major changes that occur due to cirrhosis are the death of liver cells, the formation of fibrotic cells (mast cells), cell regeneration and scar tissue that replaces normal cells (Baradero, 2008).According to Black (2014) liver cirrhosis is a progressive chronic disease characterized by extensive fibrosis (scar tissue) and nodule formation. Cirrhosis occurs when the normal flow of blood, bile and hepatic metabolism is altered by fibrosis and changes in hepatocytes, bile ducts, vascular pathways and reticular cells. Cirrhosis is the final stage in many types of liver injury. Cirrhosis of the liver usually has a nodular consistency, with bundles of fibrosis (scar tissue) and small areas of tissue regeneration. There is extensive damage to hepatocytes. Changes in heart shape change the flow of the vascular and lym
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Nursing Care Plan for Diverticular Disease - 3 Nursing Diagnosis and Interventions

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Nursing Care Plan for Diverticular Disease 1. Nursing Diagnosis : Constipation NOC 1. Bowel elimination 2. Hydration Outcomes: 1. Maintain soft stool every 1-3 days. 2. Free from discomfort and constipation. 3. Identify indicators to prevent constipation. 4. Soft and shaped feces. NIC 1. Constipation / Impaction Management 2. Monitor signs and symptoms of constipation. 3. Monitor bowel sounds. 4. Monitor stool (frequency, consistency and volume) 5. Explain the etiology and rationalization of the action against the patient. 6. Identify factors that cause constipation. 7. Support fluid intake. 8. Collaborate for laxatives. 9. Monitor for signs and symptoms of impaction. 10. Monitor bowel movements, including consistency of frequency, shape, volume, and color. 11. Consult with the doctor about the decrease / increase in frequency of bowel sounds. 12. Monitor for signs of intestinal rupture / peritonitis. 13. Describe the etiology of the problem and thoughts for the patient's actions.
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